Faur Alexandra

Bolintineanu Sorin
Țaga Roxana
Bîna Paul

Editura „Victor Babeș”

Timișoara, 2021
Authors:

Faur Alexandra
Associate Professor, MD, PhD

Bolintineanu Sorin
Professor, MD, PhD

Țaga Roxana
Assistant Professor, MD, PhD Student

Bîna Paul
Assistant Professor, MD, PhD Student

Acknowledgements: The graphic illustration was made by Bolda Bogdan Emil

(Liceul de Arte Plastice Timișoara)

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Editura „Victor Babeş”
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Colecţia: MANUALE
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ISBN 978-606-786-246-1

© 2021 Toate drepturile asupra acestei ediţii sunt rezervate.

Reproducerea parţială sau integrală a textului, pe orice suport, fără acordul scris al
autorilor este interzisă şi se va sancţiona conform legilor în vigoare.

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CONTENT

Chapter I. Head and neck embryology .......................................................... 5

1. HEAD AND NECK EMBRYOLOGY (Faur A.) ...........................................................5
2. References Chapter I .....................................................................................................14

Chapter II. Head and Neck - Topographic Regions .................................... 15

1. FRONTO-PARIETO-OCCIPITAL REGION (Bolintineanu S.).....................................16
2. TEMPORAL REGION (Faur A.) ..................................................................................20
3. ZYGOMATIC REGION (Țaga R.) ...............................................................................24
4. INFRAORBITAL REGION (Țaga R.) ..........................................................................25
5. BUCCAL REGION (Țaga R., Faur A.) .........................................................................28
6. MENTAL REGION (Țaga R., Faur A.) ........................................................................32
7. NASAL REGION (Bîna P.) ..........................................................................................35
8. THE PAROTID REGION (Bîna P., Faur A.) ................................................................42
9. THE PALPEBRAL REGION (Bîna P.) ........................................................................47
10. THE LABIAL REGION (Bîna P.) ..............................................................................51
11. THE MASTOID REGION (Bîna P.) ...........................................................................55
12. References Chapter II ..................................................................................................56

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Chapter I.
Head and neck embryology

1. Head and neck embryology

Assoc. Prof. Dr. Faur Alexandra

The importance of the head and neck embryology allows the understanding of the
normal craniofacial morphology but also provides insights into how congenital deformities
occur. The sensitive period for the future living organism is represented by the embryonic
stage which is the period between 16 days-8 weeks of the prenatal development. The embryonic
stage is the stage in which the primary germ layers differentiate into organs and systems and
this period ends when all organs are present. During this period of organogenesis, the shape of
an embryo greatly changes and an exposure to certain agents may cause major congenital
malformations. (1,2)

Around day 15 postconception the embryonic disc has two layers the epiblast and the
hypoblast and it is flanked by two spaces the amniotic cavity and the yolk sac. On the
embryonic disc along the midline of the epiblast a groove, the primitive streack, is formed.
With this primitive streak the disc has two symmetric sides, the left and right side, two surfaces,
dorsal and ventral surface and two ends, cephalic and caudal ends. During this 3rd week of
development the trilaminar embryonic disc is formed and at his level three important
structures are present the primitive streak, the notocord and the neural tube (fig 1). This disc
has three layers ectoderm, mesoderm and endoderm. In the region of the primitive streack
from the epiblast groups of cells move inward forming the mesoderm and some of the epiblast
cells displace the hypoblast and the endoderm layer is formed. The cells which remain in the
epiblast will be forming the ectoderm. The formation of the trilaminar disc is called
gastrulation.(1,2).

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 Fig. 1. Embryo development in the first 3 weeks of gestation

Cells migrating cranially through the primitive node form the notochordal process, the
future notochord, which defines the primitive axis of the embryo. The developing notochord
induces the overlying ectoderm to form the neural plate the primordium of the central nervous
system. The mesoderm layer and the notochord separate the ectoderm and endoderm layers
entirely, with the exception of the prechordal plate cranially (future oropharyngeal membrane)
and the cloacal membrane (future anus) caudally. The two membranes are demarcating the sites
of the future end and exit of the gut. The invagination of the epiblast cells through the primitive
streak results in an expansion of the embryonic disc at the cranial end of the embryo thus the
cells will begin differentiating while in the caudal end the gastrulation is continuing. In the 18
day the neural plate is formed and the neurulation process begins. (1,2)

Neurulation is the process of the neural tube formation. This process begins with the
appearance of the neural plate, which invaginates along its central axis to form the neural
groove, with neural folds on each side. From the neural folds by approaching each other in the
midline the neural crests are made. The neural crests fuse on the midline converting the neural

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groove into a neural tube. Formation of the neural tube begins in the region of the future neck
(the 4th somite) and proceeds in the cranial and caudal directions and it is open by way of the
cranial (anterior) and caudal (posterior) neuropores. Closure of the anterior neuropore occurs
on the 25th day, whereas the posterior neuropore closes on the 27th day. As the neural tube
separates from the surface ectoderm, the neural crest cells migrate to the sides of the neural
tube. The neural crest separates into the right and left part, and migrate to dorsolateral aspects
of the neural tube. (1,2)

The development of the facial region includes contribution from the ectoderm which
will help form the face and oral cavity and from the neural crest mesenchyme which has a
major contribution in the branchial arch and their derivatives. The neural crest tissue has a
pluripotent cell population derived from the crest of the neural folds during the neural tube
closure. In this closure process the epithelial and mesenchymal interacts and transforms
resulting the ectomesenchyme. Migration, proliferation and differentiation of the neural crest
cells provide the prominences of the embryo head and neck region. Any deficiencies in the
quantity and quality of the neural crest migration manifests in congenital anomaly ranging from
holoprosencephaly to clefts of the lips and dimples in the cheeks. Neural crest cells typically
emerge from the neural tube in a wave that spreads from anterior to posterior along almost the
entire neuroaxis. The cranial neural crest cell population can be divided into forebrain,
midbrain, and hindbrain domains of migrating cells. (3,4).

The skeletal and connective tissue of the face and the pharyngeal arches has as a
component ectomesenchyme from the neural crest tissue. After the anterior neuropore is closed
the oropharyngeal membrane region sinks and forms the stomodeum. The forebrain enlarges,
pushes the overlying ectoderm and creates the frontonasal process. At the level of the
oropharyngeal membrane region the ectoderm is in contact with the endoderm and forms the
aforementioned membrane which disintegrates in the fifth week in which foregut opens to the
outside. During these first 4-5 weeks of development the stomodeum is surrounded by five
facial prominences: frontonasal, maxillary (2) and mandibular (2) processes (Fig.2 and
3). The neural crest cells from the midbrain domain form part of the trigeminal, facial,
glossopharyngeal, vestibulocochlear and vagal ganglia and part of the maxillomandibular
placode. The migrating neural crest cells encounter pharyngeal endoderm with which they
interact to form the five pharyngeal arches. The growth of the first pharyngeal arches bilaterally
will produce the maxillary and mandibular prominences (4). The mandibular processes extend
towards the midline and fuse in the fifth week (5). From the lateral areas of the frontonasal

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prominences the nasal placodes develop which will sink to form first the nasal groove and then
the nasal pits bordered by the nasal processes (4). For the nasal processes the mesenchyme from
the neural crests has 2 origins. The midbrain neural crest cells migrate into forming the lateral
nasal process and the forebrain neural crest cells appear to form the medial nasal process of
the future face.

Fig. 3. Embryo at 4-6 weeks

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 The nasal pits will form the nasal sacs. The ectoderm which covers the 1/3 superior
part of each enlarging nasal sac will become olfactory epithelium. The olfactory epithelia
develop cellular buds and sends out nerve processes that encircles the neural cells of the
olfactory lobe and in the 7th week the olfactory epithelium is in the proper location. The medial
nasal process is more prominent that the lateral one and each medial one has an enlarged caudal
end called the globular process of His.

The 2 medial nasal processes form the intermaxillary segment in the sixth week. The
maxillary and mandibular prominences form the commissures of the oral cavity. The fusion
between the medial nasal process with the maxillary process will form most of the upper
lip and jaw. From the fusing of the medial nasal process results philtrum, collumela and upper
lip. The maxillary process migrates and forms the upper lip, cheek regions and upper jaw. The
lateral nasal processes and the maxillary process form the lateral area of the nose. At the
junction of these two processes the nasolacrimal groove is formed from which the nasolacrimal
duct and the lacrimal sac is developing. Between the maxillary process and the medial nasal
process is a groove called the bucconasal groove which fuses in the fifth week because of the
medial on growing maxillary process. At the posterior end of this bucconasal groove is an
epithelial membrane, the bucconasal membrane. In the 6th week the bucconasal membrane
begin to thin in a 2 layer membrane called the oronasal membrane which in the middle of the
6th week will dissolve to form the primitive posterior choana. In the 7th week the nasal cavities
are opened to outside through a nostril and posteriorly communicates with the pharynx. The
mesenchyme of the frontonasal process and the cartilage from the body of the developing
sphenoid bone will form the nasal septum, the turbinates and the paranasal sinuses. (5)

The palate is formed by elements deriving from the maxillary prominences and the
frontonasal prominence. These three prominences are initially separated in the stomodeum by
the developing tongue. As the stomodeum expands, the nasal septum descends and the tongue
withdraws the palate is formed and the stomodeum has now three chambers, two nasal fossae
and the mouth.

The lateral migration of the neural crest tissue surrounds the mesodermal cores of the
pharyngeal arches. As a consequence, the five pairs of arches described for the human embryo
are separated by ectodermal grooves externally, endodermal pharyngeal pouches internally and
have a central core of mesenchyme invaded by neural crest cells. (4)

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Pouches differentiates into:

-from the first pouch-middle ear tympanum and the Eustachian tube

-second pouch-palatine tonsils fossae

-third pouch- inferior parathyroid gland and thymus

th
-4 -superior parathyroid gland
th
-5 -forms ultimobranchial body, calcitonin C cells (4)

Grooves differentiates into:

-1st arch-external acoustic meatus, ear hillocks, pinna

-from 2nd-5th disappears

The 1st pharyngeal arch derivatives are: body of tongue, Meckel cartilage, malleus,
incus, external carotid artery, maxillary artery, the masticatory muscles, and also tensor timpani,
mylohyoid, tensor palati, anterior belly of the digastric muscle, mandibular division of the
trigeminal nerve and lingual nerve. (4)

The 2nd pharyngeal arch derivatives are: stapes, styloid process, superior part of the
body of the hyoid bone, midtongue, thyroid gland anlange, tonsils, stapedial artery (dissapears),
the facial muscles, stapedius, stylohyoid and the posterior belly of the digastric muscle, facial
nerve. (4)

The 3rd pharyngeal arch derivatives are:inferior part of the body of the body and
greater conu of the hyoid bone, root of the tongue, oral fauces, epiglottis, internal carotid artery,
stylopharyngeus muscle, and glossopharyngeal nerve. (4)

The 4th pharyngeal arch derivatives are: thyroid and laryngeal cartilages, pharynx,
epiglottis, aorta, subclavian artery, pharyngeal constrictors, levator veli palatini, palatoglossus,
palatopharyngeus and cricothyroid muscles, and the motor part of vagus nerve and superior
laryngeal nerve and the sensory nerve auricular nerve to external acoustic meatus. (4)

From the 5th pharyngeal arch the cricoid, arytenoid, corniculate cartilages, larynx,
pulmonary arteries, ductus arteriosus, the laryngeal and pharyngeal constrictors muscles, the
inferior laryngeal nerve and a part of motor and the sensory part of vagus are formed. (4)

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 Clinical correlations. The possible anomalies derived from the anomaly in development
of the pharyngeal system are:

- from the ectodermal groove derivatives: aplasia, atresia, stenosis and duplication
of the external acustic meatus, cervical (branchial) clefts, sinus, cysts, fistula.

- from the endodermal pouch derivatives: diverticulum of the auditory tube, aplasia,
atresia and stenosis of the auditory tube

- from the arches derivatives: aplasia/dysplasia of malleus, incus and mandible;

aplasia/dysplasia of stapes and styloid process; defective hyoid bone; congenital
laryngeal stenosis, cleft, atresia; hypoplastic/absent external carotid and maxillary
arteries,double aorta, aortic interruption, right aorta, persistent stapedial artery,
aortico-pulmonary septation anomalies (Di-george anomaly); deficent
masticatory, facial, stapedial and faucial muscles and absent or deficient nerves
(mandibular nerve, facial nerve, chorda tympani nerve, glossopharyngeal and
vagus nerves). (4)

The connective tissues derivatives of neural crest cells are considered to be:
ectomesenchyme of facial prominences and pharyngeal arches, bones and cartilages of facial
and visceral skeleton, portion of the ear ossicles, dermis of face and ventral aspect of the neck,
corneal mesenchime, sclera and choroid optic coats, blood vessel walls excepting endothelium;
aortic arch and arteries, dentin, periodontal ligament and cementum. The muscle tissue
derivatives of neural crest cells are considered to be: the cilliary muscles, connective tissues
and sheaths of pharyngeal arch muscles combined with mesodermal components. Nervous
tissue derivatives of neural crest cells are considered to be: leptomeninges of prosencephalon
and mesencephalon (partly), glia, Schwann sheath cells, ganglia of vestibulocochlear nerve,
autonomic ganglia, spinal dorsal root ganglia, part of the sensory ganglia for trigeminal, facial,
glosopharyngeal and vagal nerves, sympathetic ganglia and plexuses, parasymphatetic ganglia,
enteric ganglia, adeohypophysis mesenchyme, adrenomedullary cells, carotid body, part of
pineal body and the melanocyes in all tissues and melanophores of iris. (4)

Clinical correlations. If only a small number of neural crest cells are produced or they
fail to migrate to their final destinations, this can result in babies with small noses, jaws, and
ears as well as cleft palate. If neural crest cell differentiation is disrupted conditions known as
craniosynostosis can arise which are characterized by dysmorphic cranial shape, midface
hypoplasia, seizures and mental retardation. The suture mesenchyme separating the individual

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bony plates in the skull is derived from neural crest and this tissue should stay undifferentiated
to facilitate birth of the fetus as well as accommodate postnatal brain growth. Aberrant neural
crest cell differentiation results in pre-mature ossification of the suture mesenchyme which
fuses the individual skull bones (craniosynostosis) consequently restricting skull growth and
impacting upon facial and brain growth, development, and maturation (3).

Abnormalities of the neural crest migration, proliferation or differentiation is considered

responsible for a wide range of syndromes from von Recklinghausen neurofibromatosis,
acoustic neuroma, Di George, Klein -Waardenburg and up to Treacher Collins syndrome and
holoprosencephaly. (3,4). The term of holoprosencephaly (HPE) encompasses a variety of
clinical signs. So, a fetus with HPE might have a single central incisor if it is mildly affected or
a severe symptoms like unseparated eye (cyclopia) or an underdeveloped nose (3)

In the skull development the neurocranium has the the calvaria with membranous bone
origin and the cranial base which has an endochondral bone formation and the viscerocranium
derived from the facial prominences. Intramembranously or endochondrally ossification of the
neurocranium and viscerocranium components starts at 8 weeks postconception in so called
ossifications centers that coalesce to constitute the osseous components of the skull. The skull
growth is a sum of events represented by bone remodeling, apositions at the sutures and
synchondroses and transpositions and displacement of the bone tissues. (4). Remodelling of
bones involves osteoclast induced bone breakdown on the inner surface of the skull and
osteoblast-mediated thickening on the outer surface. In the normal human skull this mechanism
is important for adapting the degree of curvature of the calvarial bones to the changing
circumference of the brain; in craniosynostosis it is an important compensatory mechanism for
the premature loss of sutural growth centres. The caudal boundary of the neural crest forms a
part of the frontal bone and the tissue between the parietal bones. The interaction between the
neural crest and mesoderm forms part of the coronal, sagittal and lambdoid suture. (6)

Clinical correlations. Premature synchondrosal and calvarian fusion will result in

distorted skull shapes such as brachycephaly, plagiocephaly and scaphocephaly. (4)

The thyroid gland development

In the 4th week-thyroid is described as a depression with epithelial thickening in the

floor of the pharynx appearing like a point between the the body and the base of the tongue.
The point invaginates and forms foramen cecum=blind duct from which the thyroid primordium
develops and descends in the neck like a bilobed diverticulum to reach its location in front of

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the trachea. During migration the thyroid gland is still connected to the floor of the oral cavity
by an epithelial cord or duct-the thyroglossal duct which later becomes a solid core of cells.
The thyroid becomes functional at the end of the third month when colloid containing follicles
appear. (1,2,7)

The thyroglossal duct begins at the junction of the anterior two-thirds and posterior third
of the tongue at the level of foramen caecum and ends at the 2nd and 3rd cartilage of the trachea
where the descending pathway of the thyroid gland primordium ends and the thyroid gland
matures. The distal part of the thyroglossal duct forms the pyramidal lobe of the thyroid while
the thyroid gland is forming itself. The rest of the duct obliterates by the 10th week of gestation.
(8)

Clinical correlations. The persistence of any portion of the thyroglossal duct is

responsible for the formation of the thyroglossal duct cysts and the associated pathology of
these cysts in the head and neck region. (8)

Lingual thyroid is considered to be an ectopic tissue which is due to the failure in

migration of the thyroid gland tissue during embryogenesis along the midline of the neck from
the floor of the pharynx to the usual location over the thyroid cartilage of the larynx. The
patients with lingual thyroid have symptoms such as dysphagia, dysphonia, oral haemorrhages
and hypothyroidism (9)

The tongue develops from the first three pharyngeal arches and also from the occipital
muscles myotomes. The body of the tongue develops from the three elements of the arches
represented by tuberculum impar and the two lateral swelling and the base of the tongue
develops mainly from the 3rd pharyngeal arch and it is first present as the hypobranchial
eminence. (7)

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 2. References Chapter I
th
1. Sadler TW, Langman`Medical Embryology, 12 edition,Lippincot Williams&Wilkins, 2012
2. https://web.duke.edu/anatomy/embryology/embryology.html
3. Trainor PA. Craniofacial birth defectsȘ the role of neural crest cells in the etiology and pathogenesis
of Treacher Collins Syndrome and potential for prevention. Am J Med Genet 2010 December;0
(12): 2984-2994.doi:10.1002/ajmg.a.33454
4. Sperber GH.researchgate.net/publication/233927032. Head and Neck Embryology. Chap. 11 In
Serletti at al (Eds). ” Current Reconstructive Surgery” New York. McGraw-Hill.2012
5. Som PM, Naidich TP. Illustrated rewiew of the embryology and development of the facial region,
part 1: early face and lateral nasal cavities. AJNR AM J Neuroradiol 34: 2233-40, 2013.
http://dx.doi.org/10.3174/ajnr.A3415
6. Morris-Kay GM, Wilkie AOM. Growth of the normal skull vault and its alteration in
craniosynostoses: insights from human genetics and experimental studies. J Anat. 2005; 207:637-
653
7. Avery JK. Oral Development and Histology, second Ed,1994, Thieme Medical Publishers, New
York
8. Hussain A, Sajjad H. Anatomy, Head and Neck, Thyroid Thyroglossal Duct. [Updated 2021 Aug
11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available
from: https://www.ncbi.nlm.nih.gov/books/NBK554494/
9. Kumar SLK, Kurien NM, Jacob MM, Menon PV, Khalam AS. Lingual thyroid. Ann Maxillofac
Surg. 2015, 5(1): 104-107. doi: 10.4103/2231-0746.161103

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Chapter II.
Head and Neck - Topographic Regions

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 1. FRONTO-PARIETO-OCCIPITAL REGION

Prof. Dr. Bolintineanu S.

Limits:

• Anteriorly: supraorbital border of frontal bone and glabella

• Posteriorly: superior nuchal line and external occipital protuberance
• Laterally: superior temporal lines

Fig. 4. The skull external features

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Stratigraphy:
1. Skin is thick and covered by hair follicles, with the exception of antero-inferior part of the
region where skin is thin and mobile. Alopecia is a condition where hair follicles are missing
entirely; when some hair follicles are still present the condition is called calvitia and is more
frequent in older males.
2. Subcutaneous tissue contains numerous spans situated between the skin`s deep surface and
the muscle layer that can be found inferiorly. Presence of these spans lead solidarizes the 3
superficial layers- skin, subcutaneous tissue and muscle layer- which form the scalp. These
spans create compartments at the level of the subcutaneous tissue hence the lacking of
spreading of a pathological process that can occur at the level of subcutaneous tissue. In
the subcutaneous tissue of the fronto-parietal-occipital region the vessels and the nerves of
the region are disposed as vasculo-nervous pedicles, which enter at the level of the inferior
part of the region and orientate ascendingly towards the vertex. Because of this disposition,
the surgical incisions are done in vertical manner, to protect the vasculo-nervous pedicles.
If the pedicles are damaged during surgery, a circular tourniquet is applied. The region
contains 10 vasculo-nervous pedicles, 5 on each side:
a. Medial frontal pedicle: formed by supratrochlear vessels and medial branch
of frontal nerve. Supratrochlear artery arises from ophthalmic artery, branch of
internal carotid artery. Medial branch of frontal nerve arises from frontal nerve,
branch of ophthalmic nerve.
b. Lateral frontal pedicle: formed by supraorbital vessels and lateral branch
of frontal nerve. Supraorbital artery arises from ophthalmic artery. Lateral
branch of frontal nerve is a branch of frontal nerve, branch of ophthalmic nerve.
c. Pre-auricular pedicle: formed by superficial temporal vessels and auriculo-
temporal nerve. Superficial temporal artery is a terminal branch of external
carotid artery. Auriculo-temporal nerve is a branch of mandibular nerve.
d. Retro-auricular pedicle: formed by posterior auricular vessels and
auricular and mastoid branches of superficial cervical plexus. Posterior
auricular artery is a collateral branch of external carotid artery.
e. Occipital pedicle: formed by occipital vessels and posterior branches of the
first 3 cervical spinal nerves which can anastomose and form the posterior
cervical plexus. Occipital artery is a branch of external carotid artery.

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3. Musculo-aponeurotic layer: consists of occipito-frontalis muscle which is formed by 2
muscular parts connected by the epicranial aponeurosis (galea aponeurotica)
• Occipital part (Venter occipitalis): has a quadrangular shape with its origin
onto supreme nuchal line and mastoid process. From there, its fibers orientate
superiorly and anteriorly and end at the level of posterior border of epicranial
aponeurosis and the postero-medial surface of ear auricle
• Frontal part (Venter frontalis): is more developed than the occipital part, also
has a quadrangular shape and it is situated in the anterior part of cranial vault.
Origin is onto the anterior border of epicranial aponeurosis, anteriorly to coronal
suture, and the insertion is at the level of the skin of the forehead.

Galea aponeurotica has 4 prolongations:

• Anterior prolongation: which protrudes between the frontalis muscle fibers, separating them
in 2 halves
• Posterior prolongation: which protrudes between the occipitalis muscle fibers, separating
them in 2 halves
• 2 lateral prolongations (right and left) which protrude in the temporal region until it reaches
the zygomatic arch giving insertion to anterior auricular muscle and superior auricular
muscle.
4. Subgaleal layer: is represented by loose connective tissue which allow the scalp to glide
onto the deep bony layer
5. Osteo-periosteal layer consists of periosteum and a bony layer. The bony layer is formed
by 2 structures: one external and one internal, both composed of compact bone. Between
these layers spongy bone can be found, which is also called diploe. Below the osteo-
periosteal layer lay the cerebral hemispheres covered by their meninges. (1-6)

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Fig. 5. Superficial facial muscles

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 2. TEMPORAL REGION (Regio temporalis)

Dr. Taga R, Assoc Prof. Dr. Faur Alexandra

Temporal region is a paired topographic region of the head, situated on the lateral
sides of the scalp.

Limits:

• Superiorly: superior temporal line

• Inferiorly: zygomatic arch
• Antero-inferiorly: zygomatic process of frontal bone and frontal process of zygomatic
bone
• Posteriorly: the line that prolongates inferiorly the superior temporal line of parietal
bone
(Consult fig. 4)

Temporal region can be found between the frontal region anteriorly, occipital region
posteriorly, parietal region superiorly and zygomatic, parotic-masseteric, auricular and mastoid
regions inferiorly. At this level, temporalis muscle can be palpated by clenching the teeth
repeatedly. Pterion represent the bony landmark where 4 bones meet: frontal, temporal, parietal
and sphenoid bones and it is of high importance because it overlies the anterior division of
middle meningeal artery. At this level, if a fracture occurs and the artery ruptures it can form
an extradural hematoma, which can compress the brain and further can lead to loss of
consciousness and even death. Therefore, Pterion represents the point of entry into the cranial
vault during the removing of extradural hematoma, which need to be done as early as possible.

Stratigraphy:
1. Skin is mostly covered by hair, with the exception of a small region situated antero-
inferiorly. The name of the region comes from the Latin “tempo” meaning time, suggesting
that the passing of the time is firstly visible in this region, as it is the first region where the
white hairs appear.

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2. Subcutaneous tissue:
a. In the antero-inferior part: subcutaneous tissue is thin, permitting the visualization
of the superficial temporal vessels.
b. In the postero-superior part: subcutaneous tissue contains numerous connective
spans which connect the skin with the aponeurotic layer. At this level muscles and
blood vessels can be found:
• Superficial muscles: anterior auricular muscle, superior auricular muscle, posterior
auricular muscle, temporo-parietal muscle.
• Superficial blood vessels and superficial nerves: are represented by the preauricular
vasculo-nervous pedicle and retro-auricular vasculo-nervous pedicle
a) Pre-auricular vasculo-nervous pedicle: consists of superficial temporal artery
(terminal branch of external carotid artery), superficial temporal vein and
auriculo-temporal nerve (from mandibular nerve). Superficial temporal artery
enters the scalp in front of the root of zygomatic bone and gives off as frontal and
parietal branches.
b) Retro-auricular vasculo-nervous pedicle consists of posterior auricular artery,
posterior auricular vein and auricular and mastoid branches of superficial
cervical plexus. Posterior auricular artery enters the scalp behind the root of the ear.
c) Lymphatic vessels drain into parotid and mastoid lymph nodes.
3. Aponeurotic layer: consists of 2 layers, one superficial and one deep layer separated by
a layer of connective tissue. Superficial layer is represented by the lateral prolongation of
galea aponeurotica. Deep layer is represented by temporalis muscle fascia.

I. Galea aponeurotica (epicranial aponeurosis): is a band of dense connective tissue

which can be found between the frontalis and occipitalis muscle. Inferiorly and laterally,
galea aponeurotica gets thinner in order to insert onto temporalis fascia. On the external
surface of it superior auricular muscle, inferior auricular muscle and temporo-parietal
muscle insert.

II. Temporalis fascia: has the same shape as the temporalis muscle. Insertions:

i. Superiorly: onto the frontal process of zygomatic bone, zygomatic process

of frontal bone, temporal line of frontal bone, superior temporal line of
parietal bone; from the superior temporal line it is continuous with the
periosteum
ii. Inferiorly: the fascia splits into 2:

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 1. Superficial layer which will insert at the level of lateral surface of
zygomatic arch
2. Deep layer which will insert at the level of zygomatic arch. Between
the 2 layers middle temporal lodge can be found

4. Muscular layer: is represented by the temporalis muscle which has the origin on the
temporal fossa, inferior temporal line and deep surface of temporal fascia. The muscle is
contained inside of a lodge together with 3 deep temporal vasculo-nervous bundles. The
temporalis muscle` fascicles have a phan-shape disposition and end through a tendon which
insert onto the coronoid process of the mandible. Temporalis muscle has 3 muscular
fascicles:

TEMPORALIS M. Direction of fibers Innervation Action

Anterior fascicle almost vertical anterior temporal pulls the mandible

direction nerve upwards.

Middle fascicle oblique fibers middle temporal pulls the mandible

nerve upwards and
posteriorly

Posterior fascicle almost horizontal posterior temporal Pulls the mandible

fibers nerve posteriorly.

5. Deep blood vessels and deep nerves: cam be found between the deep surface of
temporalis muscle and temporal region periosteum and are grouped into 3 bundles:

a. Anterior deep temporal bundle: Anterior deep temporal artery (branch of maxillary
artery, which is a terminal branch of external carotid artery), anterior deep temporal vein
(which drains into pterygoid plexus) and anterior deep temporal nerve (branch of
mandibular nerve, from the trigeminal nerve)

b. Posterior deep temporal bundle: Posterior deep temporal artery (branch of

maxillary artery, which is a terminal branch of external carotid artery), posterior deep
temporal vein (which drains into pterygoid plexus), posterior deep temporal nerve
(branch from mandibular nerve, from the trigeminal nerve)

c. Middle deep temporal bundle: Middle temporal artery (branch of superficial

temporal artery, which is a terminal branch of external carotid artery), middle deep
temporal vein (drains into pterygoid plexus), middle deep temporal nerve (branch from
mandibular nerve, from the trigeminal nerve)

22
 Deep temporal nerves: one anterior and one posterior, arise from anterior trunk of
mandibular nerve. Posterior deep temporal nerve can sometimes arise from a common trunk
together with masseteric nerve, and anterior deep temporal nerve can sometimes arise from
buccal nerve. Other times, a middle deep temporal nerve can exist, arising from the anterior
trunk of mandibular trunk.

6. Bony layer consists of:

a. External periosteum layer which is continuous with the surrounding ones

b. Bony layer: is formed by temporal fossa (fossa temporalis). Floor of temporal fossa
consists of:

i. 4 bones joint together (their meeting point is called Pterion):

 Superiorly: temporal surface of frontal bone and squamous part of

parietal bone inferiorly to inferior temporal line

 Inferiorly: temporal surface of greater wing of sphenoid bone,

temporal surface of squamous part of temporal bone

ii. 4 sutures:

 Lateral part of coronal suture

 Sphenofrontal suture,

 Squamous suture

 Sphenosquamosal suture

Endocranial surface presents vascular grooves, mammillary eminences and digit-like

impressions.

c. Internal periosteum layer: between dura mater and the cerebral surface of the
squamous part of temporal bone the meningeal artery can be found. Middle
meningeal artery enters through the spinous foramen and ascends through the
thickness of dura mater, together with its anterior, middle and posterior branches.

7. Dura mater: in this region, dura mater is firmly detached, favoring the appearance of
extradural hematomas. (1-6)

23
 3. ZYGOMATIC REGION (Regio zygomatica)

Dr. Taga R

Zygomatic region is a prominent region of the face, situated superiorly to the buccal
region and it overlies the zygomatic arch and zygomatic bone.

Limits:

• Superiorly: orbital and frontal regions

• Inferiorly: parotid region

• Laterally: infratemporal region

• Medially: infraorbital region

Stratigraphy:

1. Skin

2.Malar surface of zygomatic bone, which forms the bony prominence of the region
(cheeks) inferiorly and lateral to the orbital region.

i. The malar surface is convex and perforated near its center by the
zygomaticofacial foramen, which transmits the zygomaticofacial nerve and
vessels; below this foramen is a slight elevation, which gives origin to the
Zygomaticus.

• Zygomatic arch is formed by the articulation of zygomatic process of temporal

bone together with temporal process of zygomatic bone, forming a bony ridge
between the eye and the ear. Inferiorly to the zygomatic arch, the
temporomandibular joint can be felt. (1-6)

24
 4. INFRAORBITAL REGION (Regio infraorbitalis)

Dr. Taga R

Infraorbital region is a paired lateral region of the face, situated inferiorly to the
orbital region and infrapalpebral sulcus.

Limits:

• Superiorly: infraorbital border of maxilla

• Inferiorly: a conventional line which connects labial commissure with the tragus or the
inferior border of the zygomatic arch with the posterior extremity of nasal wing

• Anteriorly and medially: nasolabial sulcus

• Posteriorly and laterally: a vertical line through the zygomatic process of frontal bone
and anterior border of masseter muscle/ zygomaticomaxillary suture

Infraorbital region is situated between orbital region and infra-temporal groove

superiorly, buccal region inferiorly, nasal region medially and zygomatic region laterally. The
infraorbital region corresponds to the upper part of the anterior surface of the maxilla and at
this level the infraorbital foramen can be found at about 1 cm inferiorly to the infraorbital
margin. This aspect is important because at this level infraorbital nerve block can be performed.

Stratigraphy:

1. Skin is thin and elastic and covered by hair follicles in males, containing numerous
sebaceous and sudoriparous glands.

2. Subcutaneous tissue is poorly developed at this level.

25
 3. Muscular layer: consists of the following muscles:

Origin Insertion Action Innervation

M. levator labii Frontal process of Nasal wing, Lifts the lips and Facial nerve
superioris maxilla, on the upper lip nasal wings
alaeque nasi medial orbital wall (breathing through
the nostrils, showing
arrogance)
M. levator labii Superior to the Upper lip Pulls the superior lip Facial nerve
superioris Foramen laterally upwards,
Infraorbitale on dilates the nostrils
the maxilla
M. levator Canine fossa Angle of Pulls the angle of the Facial nerve
anguli oris the mouth mouth medially
upwards
Orbital part of Anterior lacrimal Lateral Powerful eyelid Facial nerve
M. orbicularis crest palpebral closure
oculi Frontal process of ligament
maxilla
Lacrimal bone
Medial palpebral
ligament

4. Bony layer: consists of the anterior surface of the maxilla`s body, where the following
bony landmarks can be found:

a. Foramen infraorbitale: situated 4-10 mm inferiorly to the middle of the

infraorbital border, on the vertical line drawn through the superior pre-molars, being
in line with supra-orbital foramen. It represents the opening of the infraorbital canal
and is located superiorly to the fossa canina. Infraorbital foramen transmits:

• Infraorbital artery

• Infraorbital artery

• Infraorbital nerve (branch of maxillary division of CN V). At the level of the

infraorbital groove, the infraorbital nerve gives off the following sensory
branches:

o Posterior superior alveolar nerve

o Middle superior alveolar nerve

26
 o Anterior superior alveolar nerve

b. Canine Fossa: depression found laterally to the incisive fossa, being separated from
it by the canine eminence. It corresponds to the socket of the canine tooth.

5. Blood vessels and nerves:

a. Arteries:

• Infraorbital artery, branch from maxillary artery

• Facial artery, situated on the medial limit of the region, in the nasopalpebral
sulcus

• Transverse artery of the face, branch from superficial temporal artery

b. Veins: drain into internal jugular vein through:

• Angular vein

• Facial vein

• Transverse vein of the face.

c. Lymphatics: drain towards the submandibular lymphatic group and

superficial parotid lymphatic group

d. Nerves-Zygomatic and Buccal branches, which represent terminal branches of

facial nerve innervate mimics muscles

ii. Infraorbital nerve, branch of maxillary nerve (from trigeminal nerve)

ensures the sensory innervation of the region (1-6)

27
 5. BUCCAL REGION (Regio buccalis)

Dr. Taga R, Assoc Prof. Dr. Faur Alexandra

Buccal region represents a paired (even) topographic region situated in the central
part of the face, with an almost quadrangular shape, irregular, which forms the vast
majority of the lateral walls of the buccal vestibule- “cheeks”.

Limits:

• Superiorly: a conventional line which connects labial commissure with the tragus or
the inferior border of the zygomatic arch with the posterior extremity of nasal wing

• Inferiorly: inferior border of mandibula

• Anteriorly: a vertical line drawn at 1 cm laterally to the labial commissure, to the

posterior extremity of alaeque nasi to the inferior border of the mandible`s body

• Posteriorly: anterior border of masseter muscle

(Consult fig.5)

Buccal region can be found between infraorbital region and zygomatic region
superiorly, submental region inferiorly, oral region and mental region anteriorly and parotic-
masseteric region posteriorly. Buccal region overlies the buccinator muscle, having a
quadrangular shape, extending vertically, but this aspect depends highly on the nutritional
status, age, pathologies or physiological acts. Children and obese persons have a more
prominent and round aspect of the region because of the presence of buccal (Bichat`s) fat pad,
which contributes to the contour of the cheek area. Loss of adipose tissue in the facial region, a
normal phenomenon that happens with age, will lead to a more excavated aspect of the buccal
region. In the paresis of the facial nerve (central facial paresis) the muscles from the same part
lose their tonus and facial asymmetry occurs.

28
Stratigraphy:

1. Skin is thin and elastic and it is covered by hair follicles in males, containing numerous
sebaceous glands. In healthy individuals, the skin colour is rose-pink due to its rich
vascularization, but this aspect can be influenced by many physiological and pathological
factors.

2. Subcutaneous adipose tissue passes through the muscles of the superficial layer and it
continues at the intermuscular level. This layer is crossed by the facial vessels, parotid duct
and the terminal branches of the facial nerve.

I. At this level the buccal fat pad (Bichat`s fat pad) can be found, between the masseter
muscle and buccinator muscle. Bichat`s fat pad is an adipose mass covered by a
connective layer which prolongates towards the temporal region and infra-temporal
region.

II. Parotid duct (Stensen duct, Ductus paroticus): drains saliva from the parotid gland
into the buccal vestibule. The duct bends around the frontal edge of masseter muscle in
almost a 90 degree angle, perforates the buccinator muscle and opens at the level of the
second superior molar into the buccal vestibule

III. Juxtaoral organ (Organ of Chievitz): a small epithelial organ embedded in

connective tissue rich in nervous fibers and cells, surrounded by a perineural sheath,
that lies on the buccinator muscle, near the site where parotid duct perforates the
buccinator muscle, with an unknown function (presumably, it prevents biting of the
cheeks when chewing)

3. Muscular layer: presents a superficial layer and a deep layer, separated by an

intermuscular loose connective tissue which is continuous superficially with the
subcutaneous adipose tissue.

29
 • Superficial muscular layer consists of the following muscles:

Origin Insertion Action Innervation

M. Levator labii Frontal process of Nasal Lifts the lips and Facial nerve
superioris maxilla, on the wing, nasal wings
alaeque nasi medial orbital wall upper lip (breathing through
the nostrils, showing
arrogance)

M. Levator labii Superior to the Upper lip Pulls the superior lip Facial nerve
superioris Foramen laterally upwards,
Infraorbitale on dilates the nostrils
the maxilla

M. Zygomaticus Malar surface of Angle of Pulls the angle of the Facial nerve
major zygomatic bone the mouth mouth laterally
upwards (muscle of
joy)

M. zygomaticus Zygomatic bone, Angle of Pulls the angle of the Facial nerve
minor medial to the mouth mouth laterally
zygomaticus upwards
major insertion

M. Risorius Parotic and Angle of Broadens the mouth Facial nerve

masseteric fascias the mouth (muscle of grin) and
creates dimples

M. Depressor Inferior border of Angle of Moves the angle of Facial nerve

anguli oris Mandible the mouth the mouth
downwards
(discontent, grief)

• Deep muscular layer is formed by buccinator muscle and levator anguli oris.

o Buccinator muscle is the main cheek muscle, covered by its fascia (the
other facial muscles do not possess a fascia). It originates from the
pterygomandibular raphe (a ligament of the buccopharyngeal fascia,
from the pterygoid hamulus of the medial pterygoid plate of sphenoid
bone to the mylohyoid line of the mandible) and its fibers end
superficially, towards the skin of the angle of the mouth. Parotid duct
perforates this muscle.

30
 Origin Insertion Action Innervation

M. Pterygo- Angle of Increases the pressure within Facial nerve

Buccinator mandibular the mouth oral cavity (during blowing
raphe and chewing), prevents biting
the cheeks during mastication
M. Levator Fossa canina Angle of Pulls the angle of the mouth Facial nerve
anguli oris the mouth medially upwards

4. Mucous layer: is represented by the vestibular mucosa which lines the lateral wall of
the buccal cavity and adheres to the deep surface of buccinator muscle, explaining why
when eating big mucosa folds do not appear. Between the mucosa and the muscle layer
numerous small (minor)salivary glands can be found (buccal glands). Papilla of parotid
duct is the opening of parotid duct and can be found at the level of maxillary second
molar. This mucous layer is continuous with the gingival mucosa superiorly and
inferiorly, between them existing gingivolabial sulci.

5. Bony layer: is represented by the mandible`s body and anterior surface of the maxilla`s
body.

6. Blood vessels and nerves:

a. Facial artery enters the region at the level of inferior border of the mandible (a
region where its pulsations can be felt) and crosses the region having a sinuous
and ascending trajectory. In this region, from the facial artery arise also superior
and inferior labial arteries for the oral region. At the level of internal eye angle,
facial artery anastomoses with the angular artery, branch of ophthalmic artery,
explaining why an infection at the level of the face can easily spread
intracranially.

b. Facial vein, accompanies facial artery

c. Mental artery, branch of maxillary artery.

d. Terminal branches of facial nerve (zygomatic, buccal and marginal branch

of the mandible) innervate mimics muscles. When facial paresis occurs patients
cannot perform simple tasks as whistling or puffing and when trying to eat,
aliments are contained between their cheek and gums.

e. Branches of mandibular nerve from the trigeminal nerve ensure the sensory
innervation of the region. (1-6)

31
 6. MENTAL REGION (Regio mentalis)

Dr. Țaga R., Assoc. Prof. Dr. Faur Alexandra

Mental region (chin region) represents a median region of the inferior part of the
face, situated inferiorly to the labial region and superiorly to suprahyoid region from the
cervical regions.

Limits:

• Inferiorly: inferior border of the mandible`s body

• Superiorly: a line from the mento-labial groove prolonged towards the lines drawn at 1
cm laterally from the angle of the mouth, which represent the lateral border

• Laterally: a vertical line drawn at 1 cm laterally to the angle of the mouth to the inferior
border of the mandible

Fig. 6. External features of human face

32
 Mental region can be found between oral region superiorly, submental triangle inferiorly
and buccal region laterally. The region represents the area inferior to the lower lip and it has a
quadrangular shape, convex in all planes, sometimes presenting a median fossa called mental
fossa. At the level of the anterior surface of the mandible 3 structures are distinctive: mental
protuberance in the middle and 2 lateral paired structures called mental tubercles. Mental region
dictates the physiognomy, prominent chin being a characteristic feature of human beings.

Stratigraphy:

1. Skin is thick and covered by hair follicles forming the beard- in males. It contains
numerous sebaceous and sudoriparous glands.

2. Subcutaneous tissue is poorly represented, containing the anterior fibers of platysma

muscle and numerous connective spans. Skin is adherent to the underneath layers via
connective tracts- sometimes between mental protuberance and mental tubercles mental
fossa can be seen.

3. Muscular layer: is represented by 3 partly overlapping muscles:

Origin Insertion Action Innervation

M. Mentalis Mandible, at the Skin of the Creates chin dimple, Facial nerve
level of the lower chin everts and protrudes the
lateral incisor lower lip (“pouting”)
M. Depressor Mandible, Inferior lip Pulls the lower lip Facial nerve
labii inferior to laterally downwards,
inferioris Foramen bulges the red margin of
Mentale the inferior lip (dislike)
M. Depressor Inferior border of Angle of Moves the angle of the Facial nerve
anguli oris mandible the mouth mouth downwards
(showing grief or
discontent)

4. Bony layer: consist of a thick periosteum which covers the inferior border of
mandible`s body and the anterior surface of mandible`s body where the following
elements can be found:

a. Mental symphysis

b. Mental protuberance

33
 c. Mental tubercles

d. Mental foramina

5. Blood vessels and nerves:

a. Arteries are small branches of:

i. mental artery (branch of inferior alveolar artery from the maxillary

artery)

ii. submental artery (branch from facial artery)

iii. inferior labial artery (branch from facial artery)

b. Submental vein, which will drain into facial vein.

c. Lymphatics drain towards submental lymphatic group and

submandibular lymphatic group

d. Marginal branch of the mandible, branch of facial nerve innervates

mimics muscles

e. Fifth inferior alveolar nerve, branch of the mental nerve ensures the
sensory innervation of the region (1-6)

34
 7. NASAL REGION

Dr. Bîna Paul

The nose is the uppermost part of the respiratory tract and contains the peripheral organ
of smell.

It consists of the external nose and the nasal cavity.

The functions of the nose are:

1. Respiration.

2. Olfaction.

3. Protection of the lower respiratory passages.

4. Air conditioning of the inspired air.

5. Vocal resonance.

6. Nasal reflex functions.

The external nose is a pyramidal projection in the mid face.

1. Tip (or apex), the lower free end, flexible when palpated because it is made up of
cartilage
2. Root or bridge, the upper narrow part, between the eyes inferior to glabella it
continued with the forehead.
3. Dorsum, a border between the tip and the root where sides of the nose meet.
4. Nostrils or nares, the two piriform apertures separated from each other by a
midline nasal septum
5. Ala, the lower flared part on the side of nose. (Consult fig.6)

35
Skeleton

The skeletal framework of the external nose is bony and cartilaginous. The upper one-
third of the external nose is bony and lower two-third is cartilaginous. The bony framework is
formed by: two nasal bones, frontal processes of the maxillae, the nasal part of the frontal bone
and its nasal spine, and the bony parts of the nasal septum.

The cartilaginous framework of the nose is formed by five main cartilages: two
lateral cartilages, two alar cartilages, and one septal cartilage.

Noses aspect can vary considerably, mainly because of differences in these cartilages.
The dorsum of the nose extends from the root of the nose to the apex (tip) of the nose. The
skin over the cartilages of the nose contains many sebaceous glands. The skin extends into the
vestibule of the nose, where it has a variable number of stiff hairs (vibrissae). Because they
are usually moist, these hairs filter dust particles from air entering the nasal cavity. The junction
of the skin and mucous membrane is beyond the hair-bearing area.

The interior of the nose is divided into right and left nasal cavities by a nasal septum

Each nasal cavity communicates with the exterior through nostril (or naris) and with the
nasopharynx through the posterior nasal aperture.

Fig.7. Anatomy of the nasal cavities

36
VESTIBULE OF NOSE

It is the anteroinferior part of nasal cavity, lined by skin. The skin contains sebaceous
glands, hair follicles, and the stiff interlacing hair called vibrissae. Its upper limit on the lateral
wall of nasal cavity is marked by limen nasi. Its medial wall is formed by a mobile columella.

Boundaries

The nasal cavity proper presents the following boundaries:

Roof: The roof is narrow in front and widens near the choanae. It is horizontal in the
middle third, where it is formed by the cribriform plate of the ethmoid. Through this olfactory
nerves enter the cranial cavity from the nasal cavity. The anterior is formed by the nasal spine
of the frontal, the nasal bone and the junction of the septal and lateral cartilages. The posterior
is formed by the body of the sphenoid.

Floor: The floor is horizontal. It is formed by the upper surface of the hard palate,
anterior palatine process of maxilla and posterior by the horizontal plate of the palatine bone.

Medial wall: It is formed by nasal septum. The nasal septum is a median

osseocartilaginous

The bony part is formed by:

(a) perpendicular plate of ethmoid, which forms the posterosuperior part of the septum,
and

(b) vomer,which forms the posteroinferior part of the septum.

The cartilaginous part is formed by

1. septal cartilage, which forms the major anterior part of the septum and fits in the angle
between the vomer and perpendicular plate of ethmoid, and

2. septal processes of the two major alar cartilages.

Lateral wall: The lateral wall of the nose is complicated. It is formed by a number of
bones and cartilages

37
 The bones forming the lateral wall are:

nasal, frontal process of maxilla, lacrimal, conchae and labyrinth of ethmoid, inferior nasal
concha, perpendicular plate of palatine and medial pterygoid plate of sphenoid.

The lateral wall is divided into three areas:

1. Anterior part presents a small depressed area, the vestibule. It is lined by the skin
containing vibrissae (short, stiff curved hair).

2. Middle part is known as atrium of the middle meatus. It is limited above by a faint
ridge of mucous membrane, the agger nasi.

3. Posterior part presents three scroll-like projections, the conchae or turbinates. The
spaces separating the conchae are called meatuses. From above downwards the
conchae are superior, middle, and inferior nasal conchae. Sometimes a 4th concha, the
concha suprema is also present.

Conchae:

Superior and middle nasal conchae are the projections from the medial surface of the
ethmoidal labyrinth

Inferior concha is the longest and broadest and is an independent bone. Covered by a
mucous membrane that contains large vascular spaces

Meatuses:

Meatuses are the passages (recesses) beneath the overhanging conchae. They are
visualized once conchae are removed.

1. Inferior meatus is the largest and lies underneath the inferior nasal concha.

2. Middle meatus lies underneath the middle concha. It presents following features:

1. (a) Ethmoidal bulla

2. (b) Hiatus semilunaris

3. (c) Infundibulum

3. Superior meatus is the smallest and lies below the superior concha.

38
Openings: The lateral wall of the nose has a number of six openings.

Sites Openings
Sphenoethmoidal recess Opening of the sphenoidal air sinus
Superior meatus Opening of the posterior ethmoidal air sinuses
Opening of the middle ethmoidal air sinuses
Middle meatus Opening of the frontal air sinus
Opening of the anterior ethmoidal air sinuses
Opening of the maxillary air sinus
Inferior meatus Opening of the nasolacrimal duct (in the anterior part of meatus)

The arterial supply of the medial and lateral walls of the nasal cavity is from 5 sources:

1. Anterior ethmoidal artery (from the ophthalmic artery).

2. Posterior ethmoidal artery (from the ophthalmic artery).

3. Sphenopalatine artery (from the maxillary artery).

4. Greater palatine artery (from the maxillary artery).

5. Septal branch of the superior labial artery (from the facial artery).

The greater palatine artery reaches the septum via the incisive canal through the anterior
hard palate. The anterior part of the nasal septum is the site of an anastomotic arterial plexus
involving all five arteries supplying the septum (Kiesselbach area).

A rich submucosal venous plexus, provides venous drainage of the nose via the
spheno- palatine, facial, and ophthalmic veins. Venous blood from the external nose drains into
the facial vein via the angular and lateral nasal veins. However, recall that it lies within the
“danger area” of the face because of communications with the cavernous (dural venous) sinus.

Nerve supply of the nose, the nasal mucosa can be divided into postero-inferior and
anterosuperior portions.

The nerve supply of the postero-inferior portion of the nasal mucosa is chiefly from the
maxillary nerve, by way of the nasopalatine nerve to the nasal septum, and posterior superior
lateral nasal and inferior lateral nasal branches of the greater palatine nerve to the lateral wall.

39
 The nerve supply of the anterosuperior portion is from the ophthalmic nerve (CN V1)
by way of the anterior and posterior ethmoidal nerves, branches of the nasociliary nerve.
Most of the external nose (dorsum and apex) is also supplied by CN V. The olfactory nerves,
concerned with smell, arise from cells in the olfactory epithelium in the superior part of the
lateral and septal walls of the nasal cavity. The central processes of these cells (forming the
olfactory nerve) pass through the cribriform plate and end in the olfactory bulb, the rostral
expansion of the olfactory tract.

The paranasal air sinuses are air-containing cavities in the bones around the nasal cavity.
The paranasal air sinuses develop as mucosal diverticula of the main nasal cavity invading the
adjacent bones. They are lined by a pseudostratified ciliated columnar epithelium as in the
nasal cavity.

1. Frontal air sinuses present in the frontal bone.

2. Ethmoidal air sinuses present in the ethmoid bone.

3. Maxillary air sinuses present in the maxilla.

Sphenoidal air sinuses present in the sphenoid bone. Paranasal air sinuses perform the
following functions:

1. Make the skull lighter.

2. Add resonance to the voice.

3. Act as air conditioning chambers by adding humidity and temperature to the inspired
air.

4. Aid in the growth of facial skeleton after birth.

ETHMOIDAL CELLS

The ethmoidal cells (sinuses) are small invaginations of the mucous membrane of the
middle and superior nasal meatus between the nasal cavity and the orbit. The anterior
ethmoidal cells drain directly or indirectly into the middle nasal meatus through the ethmoidal
infundibulum. The middle ethmoidal cells open directly into the middle meatus and are
sometimes called “bullar cells”. The posterior ethmoidal cells open directly into the superior
meatus. The ethmoidal cells are supplied by ethmoidal branches of the nasociliary nerves (CN
V1).

40
SPHENOIDAL SINUSES

The sphenoidal sinuses are located in the body of the sphenoid, but they may extend
into the wings of this bone. They are divided and separated by a bony septum. Because of this
extensive pneumatization, the body of the sphenoid is thin. Only thin plates of bone separate
the sinuses from several important structures: the optic nerves and optic chiasm, the pituitary
gland, the internal carotid arteries, and the cavernous sinuses. The posterior ethmoidal arteries
and the posterior ethmoidal nerves that accompany the arteries supply the sphenoidal sinuses.

MAXILLARY SINUSES

The maxillary sinuses are the largest of the paranasal sinuses. They occupy the bodies
of the maxillae and communicate with the middle nasal meatus. Each maxillary sinus drains by
one or more openings, the maxillary ostium (ostia), into the middle nasal meatus of the nasal
cavity by way of the semilunar hiatus. The arterial supply of the maxillary sinus is mainly
from superior alveolar branches of the maxillary artery; however, branches of the descending
and greater palatine arteries supply the floor of the sinus. (1-2,7-12)

41
 8. THE PAROTID REGION

Dr. Bîna Paul, Assoc Prof. Dr. Faur Alexandra

The parotid region is the area around the ear, bounded anteriorly by anterior border of
masseter, superiorly by the zygomatic arch, posteriorly by mastoid process, and inferiorly by
line joining the angle of the mandible to the mastoid process.

The principal structures in this area are parotid gland and facial nerve.

Fig. 8. Parotid region

42
The parotid gland

The parotid gland is the largest of the three pairs of salivary glands. The parotid gland
lies in the pyramidal area, posterior to the ramus of the mandible.

It extends from external auditory meatus above, to the upper part of the carotid triangle
below; Posteriorly it overlaps/meets the anterior border of the sternocleidomastoid muscle and
anteriorly it extends over the masseter for a variable distance. The accessory parotid gland lies
between the zygomatic arch above and the parotid duct below. Several ducts from accessory
gland open into the parotid duct.

The parotid gland is enclosed in a fibrous capsule called parotid capsule.

The gland resembles a three-sided pyramid.

Apex

It projects downwards overlapping the posterior belly of digastric muscle and adjoining
part of the carotid triangle.

Superior Surface or Base

It is concave and related to the external acoustic meatus and posterior aspect of
temporomandibular joint.

Superficial Surface

It is the largest of the four surfaces. It is covered from superficial to deep by:

1. Skin.

2. Superficial fascia containing anterior branches of greater auricular nerve, lymph nodes,
and platysma.

3. Parotid fascia.

4. Deep parotid lymph nodes.

43
Anteromedial Surface

It is deeply grooved by the posterior border of the ramus of the mandible. The branches
of facial nerve emerge on face from underneath the anterior margin of this surface.

Posteromedial Surface

It is moulded onto the mastoid and styloid processes and their covering muscles. Thus
it is related to:

1. Mastoid process, sternocleidomastoid, and posterior belly of digastric.

2. Styloid process and styloid group of muscles.

The styloid process and its muscles separate the gland from internal carotid artery,
internal jugular vein, and last four cranial nerves.

The following structures enter the gland through this surface: 1. Facial nerve trunk in its
upper part. 2. External carotid artery in its lower part.

Anterior Border

It separates the superficial surface from the anteromedial surface. The following
structures emerge underneath this border: 1.Temporal branch of the facial nerve.2. Zygomatic
branch of the facial nerve.3. Transverse facial vessels.4. Upper buccal branch of the facial
nerve. 5. Parotid duct. 6. Lower buccal branch of the facial nerve. 7. Marginal mandibular
branch of the facial nerve.

Posterior Border

It separates the superficial surface from the posteromedial surface.

The following structures emerge underneath this border:

1. Posterior auricular vessels.

2. Posterior auricular branch of the facial nerve.

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STRUCTURES PRESENT WITHIN THE PAROTID GLAND

Three main structures either in part or in whole traverse the gland and branch within it.
From superficial to deep these are: 1. Facial nerve.2. Retromandibular vein. 3. External carotid
artery.

The facial nerve is most superficial. It enters the gland through the upper part of the
posteromedial surface and divides into its terminal branches within the gland.

The five terminal branches of the facial nerve radiate like a goose-foot through the
anterior border of the gland and supply the muscles of facial expression.

The external carotid artery pierces the lower part of the posteromedial surface to enter
the gland. Within the gland it divides into superficial temporal and maxillary arteries.

Parotid Duct (Stenson’s Duct)

Parotid duct, about 5 cm long, emerges from the middle of the anterior border of the
gland and opens into the vestibule of the mouth opposite the crown of upper second molar tooth.
The duct has a tortuous course to provide a valve-like mechanism to prevent the inflation of the
duct system during excessive blowing of the mouth as in trumpet blowing.

NERVE SUPPLY

1. Parasympathetic (secretomotor) supply through auriculotemporal nerve. The

preganglionic fibres arise from the inferior salivatory nucleus in the medulla and pass
successively through glossopharyngeal nerve, tympanic branch of glossopharyngeal, tympanic
plexus and lesser petrosal nerve to relay into otic ganglion. Postganglionic fibres arise from
the cells of the ganglion and pass through the auriculotemporal nerve to supply the parotid
gland. The stimulation of parasympathetic supply produces watery secretion.

2. Sympathetic supply: It is derived from sympathetic plexus around external carotid artery
formed by postganglionic fibres derived from superior cervical sympathetic ganglion. The
preganglionic sympathetic fibres arise from the lateral horn of T1 spinal segment. The
sympathetic fibres are vasomotor and their stimulation produces thick sticky secretion.

3. Sensory supply: It is derived from: (a) Auriculotemporal nerve. (b) Great auricular nerve
(C2 and C3). The C2 fibres are sensory to the parotid fascia.

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VASCULAR SUPPLY

The arterial supply of parotid gland is derived from the external carotid and superficial
temporal arteries.

The venous drainage of parotid gland takes place into retromandibular and external
jugular veins.

The facial nerve

The facial nerve comes out of cranial cavity through the stylomastoid foramen, between
the styloid and mastoid processes of the temporal bone.

After emerging enters the posteromedial aspect of the parotid gland on the superficial
plane. In the gland, it runs superficial to the retromandibular vein for about 1 cm and then
divides into two trunks: (a) the temporofacial, and (b) the cervicofacial.

Branches:

1. Posterior auricular nerve: It supplies occipital belly of occipitofrontalis,

auricularis posterior, and auricularis superior (intrinsic muscles of the ear).

2. Branch to the posterior belly of digastric

3. Terminal branches:

• (a) Temporal branch—run upwards and cross the zygomatic arch.

• (b) Zygomatic branches—run below and parallel to the zygomatic arch.

• (c) Buccal branches—are two in number. The upper buccal nerve runs above the parotid
duct and the lower buccal nerve runs below the duct.

• (d) Marginal mandibular (also called mandibular) branch—runs forwards below the
angle of the mandible, deep to the platysma. It then crosses the body of the mandible to
supply the muscles of the lower lip and chin.

• (e) Cervical branch—runs downwards and forwards to reach the front of the neck, to
supply the platysma.

The long axis of each orbit (orbital axis) passes backwards and medially. (1-2,7-12)

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 9. THE PALPEBRAL REGION

Dr. Bîna Paul

Limits:

- Superior: Suprapalpebral sulcus

- Inferior: Infrapalpebral sulcus

Orbital region

The orbital region is the area of the face overlying the orbit and eyeball and includes
the upper and lower eyelids and lacrimal apparatus.

Orbits

The orbits are a pair of pyramidal-shaped bony cavities in the facial skeleton located
one on either side of the root of the nose and provides sockets for rotatory movements of the
eyeballs. Each orbit is a quadrangular pyramid with apex directed behind at the optic canal and
base forward. The medial walls of the two orbits, separated by the ethmoidal sinuses and the
upper parts of the nasal cavity.

The orbits and orbital region anterior to them contain and protect the eyeballs and
accessory visual structures, which include the:

• Eyelids, which bound anteriorly, protecting the anterior part of the eyeball.

Extra-ocular muscles

• Nerves and vessels of the eyeballs and muscles.

• Orbital fascia surrounding the eyeballs and muscles.

• Mucous membrane (conjunctiva) lining the eyelids and anterior aspect of the eyeballs,
and most of the lacrimal apparatus, which lubricates it.

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 All space within the orbits not occupied by these structures is filled with orbital fat;
thus, it forms a matrix in which the structures of the orbit are embedded. The quadrangular
pyramidal orbit has a base, four walls, and an apex:

• The base of the orbit is outlined by the orbital margin, which surrounds the orbital
opening.

• The superior wall (roof) is horizontal and is formed mainly by the orbital part of the
frontal bone, which separates the cavity from the anterior cranial fossa. Near the apex
of the orbit, the superior wall is formed by the lesser wing of the sphenoid.
Anterolaterally, in the orbital part of the frontal bone, is the fossa for lacrimal gland
(lacrimal fossa).

• The medial walls of the orbits are parallel and are formed primarily by the orbital plate
of ethmoid bone, along with contributions from the frontal process of the maxilla,
lacrimal, and sphenoid bones. Anteriorly, the medial wall is dissected by the lacrimal
groove and fossa for lacrimal sac;

• The inferior wall (orbital floor) is formed mainly by the maxilla and partly by the
zygomatic and palatine bones. The thin inferior wall is shared by the orbit and maxil-
lary sinus. It slants inferiorly from the apex to the inferior orbital margin. The inferior
wall is demarcated from the lateral wall of the orbit by the inferior orbital fissure, a
gap between the orbital surfaces of the maxilla and the sphenoid.

• The lateral wall is formed by the frontal process of the zygomatic bone and the
greater wing of the sphenoid. This is the strongest and thickest wall, which is impor-
tant because it is most exposed and vulnerable to direct trauma. Its posterior part
separates the orbit from the temporal and middle cranial fossae. The lateral walls of the
contralateral orbits are nearly perpendicular to each other.

• The apex of the orbit is at the optic canal in the lesser wing of the sphenoid just medial
to the superior orbital fissure.

• The widest part of the orbit corresponds to the equator of the eyeball (Fig. 7.45A), an
imaginary line encircling the eyeball equidistant from its anterior and posterior poles.
The bones forming the orbit are lined with periorbita, the periosteum of the orbit. The
periorbita is continuous:

• At the optic canal and superior orbital fissure with the periosteal layer of the dura mater.

48
 • Over the orbital margins and through the inferior orbital fissure with the periosteum
covering the external surface of the cranium (pericranium).

• With the orbital septa at the orbital margins.

• With the fascial sheaths of the extra-ocular muscles.

• With the orbital fascia that forms the fascial sheath of the eyeball.

Eyelids and Lacrimal Apparatus

• The eyelids and lacrimal fluid, secreted by the lacrimal glands, protect the cornea and
eyeballs from injury and irritation (e.g., by dust and small particles).

EYELIDS

• The eyelids are moveable folds that cover the eyeball anteriorly when closed, thereby
protecting it from injury and exces- sive light. They also keep the cornea moist by
spreading the lacrimal fluid. The eyelids are covered externally by thin skin and
internally by transparent mucous membrane, the palpebral conjunctiva. This part of
the conjunctiva is thin and transparent and attaches loosely to the anterior surface of the
eyeball.

• The conjunctival sac is the space bound by the palpebral and bulbar conjunctivae; it is
a closed space when the eyelids are closed, but opens via an anterior aperture, the
palpebral fissure, when the eye is open (eyelids are parted).

• The superior (upper) and inferior (lower) eyelids are strengthened by dense bands of
connective tissue, the superior and inferior tarsi (singular = tarsus). Fibers of the
palpebral portion of the orbicularis oculi (the sphincter of the palpebral fissure) are in
the connective tissue superficial to the tarsi and deep to the skin of the eyelids.
Embedded in the tarsi are tarsal glands that produce a lipid secretion that lubricates the
edges of the eyelids and prevents them from sticking together when they close. The lipid
secretion also forms a barrier that lacrimal fluid does not cross when produced in normal
amounts.

• The eyelashes (L. cilia) are in the margins of the eyelids. The large sebaceous glands
associated with the eyelashes are ciliary glands.

49
 Between the nose and the medial angle of the eye is the medial palpebral ligament,
which connects the tarsi to the medial margin of the orbit. The orbicularis oculi originates and
inserts onto this ligament. A similar lateral palpebral ligament attaches the tarsi to the lateral
margin of the orbit. The orbital septum is a fibrous membrane that spans from the tarsi to the
margins of the orbit, where it becomes continuous with the periosteum. It keeps the orbital fat
contained and, owing to its continuity with the periorbita, can limit the spread of infection to
and from the orbit. The septum constitutes in large part the posterior fascia of the orbicularis
oculi muscle. (1-2,7-12)

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 10. THE LABIAL REGION

Dr. Bîna Paul

Limits

- Superior: nasolabial groove (nasolabial sulcus), posterior border of the nose wing

- Inferior: the horizontal line passing through mento-labial fold (mento-labial sulcus)

- Lateral: the vertical line passing one centimeter lateral to the angle of the mouth
(angulus oris)

(Consult fig.6)

Stratification:

1. Skin layer is thicker and contains hair, sweat glands, and sebaceous glands

2. Subcutaneous cellular tissue, wich is more to be found lateral

3. Muscular layer: The principal muscle of the lips is the circumferential orbicularis
oris, functioning primarily as a sphincter for the oral aperture. The other ones are part of the
peripheral system formed by radial muscle fascicles building ten muscles, considered muscles
of facial expression. The majority of the mouth muscles are connected by a fibromuscular hub
onto which their fibers insert. This structure is called the modiolus, it is located at the angles of
the mouth and it is primarily formed by the buccinator, orbicularis oris, risorius, depressor anguli
oris and zygomaticus major muscles.

A. Orbicularis oris muscle is one of the muscles of facial expression and its primary
action is as the sphincter of the mouth. It consists of two parts; peripheral and marginal, with
the border between them corresponding to the margin between the lips and the surrounding skin.
Both portions originate from the modiolus, which is a fibromuscular structure found on the lateral
sides of the mouth where several facial muscles converge. The peripheral portion passes medially
into the labial areas to insert on the dermis of the lips. In the midline, some of the fibers blend
with their respective counterparts, forming the philtrum of the mouth. The marginal
portion passes from the modiolus on one side to the modiolus on the other side of the mouth.
Some of the fibers curl upon themselves, forming the vermilion border, which is the demarcation
between the lips and the adjacent skin.

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 B. Buccinator muscle. The buccinator muscle plays an active role along with
orbicularis oris and superior constrictor muscle during swallowing, mastication, blowing, and
sucking. It is composed of three parts; superior, inferior and posterior. The superior part
originates from the alveolar process of maxilla, opposite the three maxillary molar teeth. The
inferior part originates from the buccinator ridge of mandible, opposite the three mandibular
molar teeth. The posterior part originates from the anterior margin of the pterygomandibular
raphe behind the third mandibular molar. All three parts of the buccinator converge towards the
angle of the mouth and fill the space between the upper and lower jaws. At the angle of the
mouth, the fibers of the buccinator blend with other facial muscles, including orbicularis oris,
risorius, depressor anguli oris and zygomaticus major, forming the modiolus. The buccinator
muscle is pierced by the parotid duct (Stenson's duct) after it crosses the masseter muscle and
turns medially at the anterior border of the muscle to open in the oral cavity into a small papilla
opposite the maxillary second molar.

C. The levator labii superioris is a short triangular muscle that originates from the
zygomatic process of maxilla and maxillary process of the zygomatic bone. It courses downwards
and medially to attach on the skin. His action is significant in making certain facial expressions,
such as smiling, grinning and contempt.

D. The levator labii superioris alaeque nasi is a slender, strap-like muscle found on both
sides of the nose. It originates from the upper part of the frontal process of the maxilla and passes
inferolaterally, inserting on the perichondrium and the skin over the major alar cartilage of the
nose. Some of the fibers pass into the lateral part of the upper lip and with levator labii superioris
and orbicularis oris. The function of the levator labii superioris alaeque nasi is to elevate and evert
the upper lip, as well as to elevate, deepen and increase the curvature of the nasolabial furrow.

E. The zygomaticus minor, similarly to its major counterpart, arises from the lateral
surface of the zygomatic bone and extends diagonally towards the lips. It inserts on the skin of
the upper lip, medial to the zygomaticus major. The zygomaticus minor acts in harmony with
other tractors of the upper lip to elevate and evert the upper lip, thereby contributing to a variety
of facial expressions such as smiling, frowning or grimacing.

F. The zygomaticus major is a thin muscle that arises from the lateral surface of the
zygomatic bone and extends diagonally to the angle of the mouth. Here, it contributes to the
formation of the modiolus by interlacing with several other facial muscles. The function of the

52
zygomaticus major involves elevating and everting the angle of the mouth superolaterally,
thereby producing a smile in synergy with other muscles.

G. The depressor anguli oris is a triangular muscle situated lateral to the chin on each
side of the face. It arises from the oblique line and mental tubercle of mandible and courses almost
vertically upwards to attach at the modiolus. The depressor anguli oris acts to depress the angle
of the mouth, which contributes to expressing feelings of sadness or anger. In addition, this
muscle assists in opening the mouth during speaking or eating.

H. The risorius is a highly variable and inconsistent muscle of the buccolabial group. It
arises from several origin points that may include the fascia of the parotid gland, fascia of
the masseter and platysma muscles, and occasionally the zygomatic arch. The fibers of the
risorius converge medially and course horizontally towards the angles of the mouth.

I. The depressor labii inferioris is a short quadrangular muscle found in the chin region.
It originates from the oblique line of mandible while being continuous with the labial part of the
platysma . The muscle courses superomedially to insert on the skin and submucosa of the lower
lip.

J. The mentalis is a short conical muscle located in the chin area. It arises from the
incisive fossa of mandible and descends inferiorly to insert on the skin of the chin at the level of
the mentolabial sulcus of the mandible. The mentalis muscle acts to depress and evert the base of
the lower lip, while also creating wrinkles on the skin of the chin.

4. Glandular layer wich contains a lot minor of salivary glands.

5. The reddish skin is a transition layer between the outer, hair-bearing tissue and the
inner mucous membrane. The interior surface of the lips is lined with a moist mucous membrane
that continues with the gum.

6. I. The labial arteries are branches from the facial artery. The labial artery perfuses the
lips, nose, and muscles around the lip region. As the superior labial artery traverse across the
upper lip, it will anastomose with the Kiesselbach plexuses and the contralateral superior labial
artery.The upper lip region receives blood from the superior labial artery. The anastomosis
between the two labial arteries provides collateral blood flow to each other.

II. The inferior labial artery branches off the facial artery around the same region as
the superior labial artery. The inferior labial artery anastomoses with the contralateral inferior
labial artery and mental arteries.

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 The branching of the labial arteries from the facial artery and the anastomoses with
the contralateral side forms a network around the lips. This network helps perfuse the lips and
the muscles in this region. The anastomose network of vessels can provide blood flow to either
side if one side becomes compromised.

III. The nerve that is involved in opening and closing the mouth is the trigeminal
nerve. This nerve innervates the muscles used for mastication. The orbicularis oris muscle
receives innervation from the facial nerve. The facial nerve also innervates muscles that attach
to the lips used in facial expression. (1-2,7-12)

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 11. THE MASTOID REGION

Dr. Bîna Paul

The mastoid region is located at the lateral part of the head and includes the mastoid
part of the temporalis bone and the soft tissue layers that cover it.

Limits:

- superior: supramastoid crest

- inferior: mastoid process

- anterior: vertical line of the posterior border of the external acoustic meatus

- posterior: margo occipitalis (occipital border temporal bone)

Stratification:

1. Skin, which is thick at this level; superior and posterior covered my hair.

2. The subcutaneous tissue, traversed by fibrous fascial layer. Through this fibrous
layer are muscles, blood vessels and nerves: posterior auricular muscle, posterior auricular
artery, posterior auricular vein. Great auricular nerve originating from the cervical plexus and
posterior auricular nerve from the facial nerve.

3. Muscular layer, at this level we find the tendons of the sternocleidomastoidan

muscle and splenius capitis covered by the superficial layer of the deep cervical fascia.

4. Bone structure, pneumatised or air filled by the mastoid air cells. (1-2,7-12)

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 12. References Chapter II

1. Bolintineanu Sorin, Vaida Monica, Saragan Izabella, Paduraru Dumitru, Anatomie Topografica
II, Editura Eurostampa Timisoara 2008

2. Singh V. Textbook of Anatomy. Head, Neck and Brain-second edition, 2014

3. Albu 1998. Anatomie topografica

4. Pantea Corina,E Mirton 2008 Ghid de Anatomy topografica,

5. Bartleby Grey 1918

6. Sobotta Atlas of Anatomy 16th Edition, Elsevier ,2018

7. Moore K.L. Clinically Orientes Anatomy. Seved Ed. Lippincott Williams & Wilkins. 2014

8. Saladin K. Human Anatomy. The McGraw-Hill Companies.2004

9. https://www.ncbi.nlm.nih.gov/books/NBK546631/

10. https://onlinelibrary.wiley.com/doi/pdf/10.1002/lio2.271

11. Bolintineanu S., Vaida M., Șișu AM., Pop E., Petrescu C., Matu C., Samfirescu E., Roșu L.,
Pusztai A., Stoican L., Băcean A., Anatomia Capului și Gâtului, Editura Eurostampa, 2016.

12. Prundeanu H, Motoc A, Prundeanu C, Grigoriță L, Băcean O, Moise M. Anatomy Tests for
Medical Students.Art Press, 2014

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